Clinical Opiate Withdrawal Scale

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Clinical Opiate Withdrawal Scale (COWS)

Clinical Opiate Withdrawal Scale (COWS) is a method used by registered practitioners to measure the severity of a patient's opioid withdrawal symptoms. This method consists of a series of 11 topics each comprising 4 - 5 common symptoms experienced by a patient undergoing opioid withdrawal. In each topic a rank is given depending on what the patient responds to. Generally, 0 is considered to be no symptom shown and 4 or 5 is considered to be the most common and severe symptom shown. These results are then added up and a final diagnosis is made based on the value obtained. This test is crucial as it allows the practitioner to assess the physiological and psychological behaviours of the patient as well as the severity of each symptom during the duration of the examination. [1] The results are grouped into 3 categories of mild, moderately severe and severe. Mild consists of 5 to 12 points, moderately severe consists of 13 to 24 points and anything above 36 points is severe and requires direct medical attention. [2]

Contents

Scales measuring withdrawal symptoms examine the dependence of an individual on the opioids consumed before undertaking any sort of medical induction such as buprenorphine. Measuring opioid withdrawal symptoms was first introduced to clinics, hospitals and used as a source of evidence for researchers around the mid-1930s. [1] Over time, the progression and development in health and medicine allowed the introduction of new and more advanced scales which tested for more signs and symptoms. The most recent scale that has been introduced is COWS.

This useful tool provides the opportunity for practitioners to ensure an effective and efficient treatment process and researchers the ability to unlock new developments within the area of study.

Types of opioids

An opioid would be classified as any form of synthetic substance that will bind to the opioid receptors within the human brain. These receptors are located in the parts of the brain that generally monitor and maintain pain. There are many heavily regulated prescription medications and most of these are used as strong painkillers. Main opioid drug ingredients include codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, and tapentadol, among others.

Commonly prescribed schedule 8 opioid medications in Australia Schedule 8 meds.png
Commonly prescribed schedule 8 opioid medications in Australia

These analgesic drugs bind and acts on opioid receptors in both the gastrointestinal and central nervous system to alleviate moderate to severe pain. This sedating medication acts on receptors known as mu-receptors to reduce pain radiation across the body. [3] These can come in the form of extended release medication or immediate release depending on the condition and type of medication being consumed.

Effect of opioid

Opioids are commonly used for patients who are undergoing cancer treatment, chronic pain and postoperative pain. [4] Although these drugs are suitable for treatment, in long term patients or a misuse of these drugs can increase the risk of toxicity, sleep apnea, abnormal decrease to pain tolerance. [5] Excessive or prolonged opioid use can internally affect many organs which in turn can suppress immunity. One of the main functional systems of the body affected by opioid use is the endocrine function. If this system is affected much like the domino effect, many other bodily functions will be triggered. These functions include reduced sexual function as a result of libido reduction, infertility, mood disorders, respiratory depression, osteoporosis and possibly osteopenia. [5] If these functions are affected, the recovery process will be more difficult as it will require constant patient care through the use of more medications, tests and scans.

Application

Clinical Opioid Withdrawal Scale more commonly known as COWS is a method used to measure opioid withdrawal symptoms for both inpatients and outpatients. This intricate scaling system allows the analysis of patient condition. Each question in this test provides the opportunity for the practitioner to identify the severity and the type of opioid withdrawal symptoms being experienced by the patient. As shown in table 1 below these are the examinable topics which are generally rated a number between 0 to 4 depending on the patient's current condition. In some COWS, a rating of 5 can also be given (shown in the table 1 below). The annotated table lists the signs and symptoms that are being monitored at score 0 and 4. However, it is important to consider that the numbers 1,2 and 3 are also awarded depending on the type and severity of signs and symptoms being experienced by the patient.

Table 1: COWS made simple

Resting Pulse rate

This is the first symptom that is tested once the patient has been sitting down or lying down for at least a minute. The normal range would be between 80-bpm if not less than that (depending on their age and weight) in which case would be scored 0. A pulse that exceeds the 120-bpm mark is given a score of 4.

Gastrointestinal upset

This is also a fundamental part of the assessment as this is the body’s way to tell you something is wrong and is rated based on the last half an hour. If they feel no symptoms of nausea or gastrointestinal irritation, they get a score of 0. Moreover, if they experience consistent episodes of nonstop vomiting or diarrhea, they will be given a score of 5. 

Sweating

The rate of patient sweat is scored based on the last half an hour with disregard to any physical fitness activity or a rise in room temperature. Similarly, to the previous topic, 0 is scored if patient's body temperature is within the normal range of ~37 °C and if they are showing any signs of uncontrollable chills or sweat streaming down their face and body, a score of 4 is given.

Tremor

This refers to the unusual movements of the body. If patient is in stable condition with no odd movements then they are given a score of 0 but if they are experiencing tremor and muscle twitches throughout examination, they get a score of 4.

Restlessness

This part of the scale is examined throughout the duration of the assessment. If the patient can remain calm and sit still through the test, they will be given a score of 0. However, if they are quite agitated, restless and cannot sit still throughout the examination, they will be given a score of 5.

Yawning

This is an easy part of the assessment but requires focus to detail as this symptom should be monitored throughout the test. No yawning is an indication of a score of 0, whereas a score of 4 specifies the patient has constantly been yawning throughout the process of the test.

Pupil Size

This is a crucial feature to notice as the dilation size of the pupil can provide a sufficient amount of information. If the pupil is at a normal size, then they will be given a score of 0. If their pupils are dilated all the way and the iris is barely visible, a score of 5 will be given as this indicates that the ciliary muscle of the eye is temporarily paralysed and therefore the pupils cannot constrict as a result of misuse or overuse of addictive medications.

Anxiety or Irritability

This section is fairly similar to the restlessness section however the main difference to consider is if the patient cannot participate in the test because it is difficult for them to focus or sit still because they are irritated or anxious a score of 4/5? will be given. If the opposite occurs and they don’t have any symptom, they get a score of 0.

Bone or Joint Aches

This section does not take into account any previous medical condition such as osteoporosis or osteoarthritis, it only examines any recent or new joint pains and aches that have occurred. If there are no signs of pain, 0 is given. If they are unable to sit in a still position due to pain discomfort or if they are holding on to area of pain a score of 4 will be given. 

Gooseflesh Skin

This takes into account the texture of the skin. The condition and texture need to be examined as it can identify if they are cold, in shock or if they are frightened. If they have smooth skin, they are given 0. If they have very defined and visible piloerection skin due involuntary muscle contraction near the patient’s hair follicles, they will be given a score of 5.

Runny Nose or Tearing

Much like the yawning section, this is also a fairly straightforward part to examine. Previous medical history of allergies or cold and flu symptoms are disregarded. If there are no signs or symptoms, 0 is given. If they are continuously sniffing or have an aggressive runny nose and runny eyes, 4 is given.

Total

All of the scores given will then be added up and a total score is given. The practitioner’s initials are noted, and a final diagnosis will be made. If patient signs and symptoms tally up to 0 (rare case) they need to go under further examinations is they are unwell as it could be as a result of another condition. However, if they receive results over 36, they need to go under immediate care and treatment as this is as a result of severe opioid withdrawal.

Any total score in between 0- 36 is categorised into 3 groups (5-12, 13-24 and 25-36) and based on which category the patient falls under, the severity of condition is diagnosed (mild, moderate and moderately severe).

This table was summarised and annotated based on the scale provided in the Clinical Opiate Withdrawal Scale pdf from the National Institute on Drug Abuse – Advancing Addiction Science. [1]

Post diagnosis

After being diagnosed with opioid withdrawal syndrome through the use of the scale, immediate medical attention is required. One of the most common first line of treatments administered is Buprenorphine. There are 3 factors that need to be taken into consideration whilst treating the patient with this multi-use drug;

  1. Induction
  2. Stabilisation
  3. Maintenance

These 3 factors are crucial in ensuring full and safe patient recovery. [6] This opioid agonist will decrease toxicity during overdose as it acts as an antagonist for the opioid receptors in the body which then inhibits the adverse effects of opioid use. [7] This will then allow the patient to become stabilised which then allows the practitioner to maintain and monitor the patient's stable condition.

Related Research Articles

<span class="mw-page-title-main">Methadone</span> Opioid medication

Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid agonist used for chronic pain and also for opioid use disorder. It is used to treat chronic pain, and it is also used to treat addiction to heroin or other opioids. Prescribed for daily use, the medicine relieves cravings and removes withdrawal symptoms. Withdrawal management using methadone can be accomplished in less than a month, or it may be done gradually over a longer period of time, or simply maintained for the rest of the patient's life. While a single dose has a rapid effect, maximum effect can take up to five days of use. After long-term use, in people with normal liver function, effects last 8 to 36 hours. Methadone is usually taken by mouth and rarely by injection into a muscle or vein.

<span class="mw-page-title-main">Oxycodone</span> Opioid medication

Oxycodone, sold under various brand names such as Roxicodone and OxyContin, is a semi-synthetic opioid used medically for treatment of moderate to severe pain. It is highly addictive and is a commonly abused drug. It is usually taken by mouth, and is available in immediate-release and controlled-release formulations. Onset of pain relief typically begins within fifteen minutes and lasts for up to six hours with the immediate-release formulation. In the United Kingdom, it is available by injection. Combination products are also available with paracetamol (acetaminophen), ibuprofen, naloxone, naltrexone, and aspirin.

<span class="mw-page-title-main">Hydromorphone</span> Opioid drug used for pain relief

Hydromorphone, also known as dihydromorphinone, and sold under the brand name Dilaudid among others, is a morphinan opioid used to treat moderate to severe pain. Typically, long-term use is only recommended for pain due to cancer. It may be used by mouth or by injection into a vein, muscle, or under the skin. Effects generally begin within half an hour and last for up to five hours. A 2016 Cochrane review found little difference in benefit between hydromorphone and other opioids for cancer pain.

<span class="mw-page-title-main">Pain management</span> Interdisciplinary approach for easing pain

Pain management is an aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

Drug withdrawal, drug withdrawal syndrome, or substance withdrawal syndrome, is the group of symptoms that occur upon the abrupt discontinuation or decrease in the intake of pharmaceutical or recreational drugs.

<span class="mw-page-title-main">Opioid</span> Psychoactive chemical

Opioids are a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. Opioids work in the brain to produce a variety of effects, including pain relief. As a class of substances, they act on opioid receptors to produce morphine-like effects.

<span class="mw-page-title-main">Carisoprodol</span> Muscle relaxant medication

Carisoprodol, sold under the brand name Soma among others, is a medication used for musculoskeletal pain. Use is only approved for up to three weeks. Effects generally begin within half an hour and last for up to six hours. It is taken orally.

<span class="mw-page-title-main">Opioid use disorder</span> Medical condition

Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are important components of opioid use disorder.

<span class="mw-page-title-main">Buprenorphine</span> Opioid used to treat pain & opioid use disorder.

Buprenorphine, sold under the brand name Subutex among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection, as a skin patch (transdermal), or as an implant. For opioid use disorder, it is typically started when withdrawal symptoms have begun and for the first two days of treatment under direct observation of a health-care provider.

<span class="mw-page-title-main">Sufentanil</span> Synthetic opioid analgesic drug

Sufentanil, sold under the brand names Dsuvia and Sufenta, is a synthetic opioid analgesic drug approximately 5 to 10 times as potent as its parent drug, fentanyl, and 500 times as potent as morphine. Structurally, sufentanil differs from fentanyl through the addition of a methoxymethyl group on the piperidine ring, and the replacement of the phenyl ring by thiophene. Sufentanil first was synthesized at Janssen Pharmaceutica in 1974.

Substance dependence, also known as drug dependence, is a biopsychological situation whereby an individual's functionality is dependent on the necessitated re-consumption of a psychoactive substance because of an adaptive state that has developed within the individual from psychoactive substance consumption that results in the experience of withdrawal and that necessitates the re-consumption of the drug. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

<span class="mw-page-title-main">Opioid antagonist</span> Receptor agonist that acts on one or more of the opioid receptors

An opioid antagonist, or opioid receptor antagonist, is a receptor antagonist that acts on one or more of the opioid receptors.

<span class="mw-page-title-main">Lofexidine</span> Medication used for opioid withdrawal

Lofexidine, sold under the brand name Lucemyra among others, is a medication historically used to treat high blood pressure; today, it is more commonly used to help with the physical symptoms of opioid withdrawal. It is taken by mouth. It is an α2A adrenergic receptor agonist. It was approved for use by the Food and Drug Administration in the United States in 2018.

An equianalgesic chart is a conversion chart that lists equivalent doses of analgesics. Equianalgesic charts are used for calculation of an equivalent dose between different analgesics. Tables of this general type are also available for NSAIDs, benzodiazepines, depressants, stimulants, anticholinergics and others.

<span class="mw-page-title-main">Opioid overdose</span> Medical condition

An opioid overdose is toxicity due to excessive consumption of opioids, such as morphine, codeine, heroin, fentanyl, tramadol, and methadone. This preventable pathology can be fatal if it leads to respiratory depression, a lethal condition that can cause hypoxia from slow and shallow breathing. Other symptoms include small pupils, and unconsciousness, however its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including permanent brain damage.

Neonatal withdrawal or neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) is a withdrawal syndrome of infants after birth caused by in utero exposure to drugs of dependence, most commonly opioids. Common signs and symptoms include tremors, irritability, vomiting, diarrhea, and fever. NAS is primarily diagnosed with a detailed medication history and scoring systems. First-line treatment should begin with non-medication interventions to support neonate growth, though medication interventions may be used in certain situations.

<span class="mw-page-title-main">Buprenorphine/naloxone</span> Opioid treatment

Buprenorphine/naloxone, sold under the brand name Suboxone among others, is a fixed-dose combination medication that includes buprenorphine and naloxone. It is used to treat opioid use disorder, and reduces the mortality of opioid use disorder by 50%. It relieves cravings to use and withdrawal symptoms. Buprenorphine/­naloxone is available for use in two different forms, under the tongue or in the cheek.

<span class="mw-page-title-main">Opioid withdrawal</span> Withdrawal symptoms of opiates

Opioid withdrawal is a set of symptoms arising from the sudden withdrawal or reduction of opioids where previous usage has been heavy and prolonged. Signs and symptoms of withdrawal can include drug craving, anxiety, restless legs, nausea, vomiting, diarrhea, sweating, and an increased heart rate. Opioid use triggers a rapid adaptation in cellular signalling pathways that means, when rapidly withdrawn, there can be adverse physiological effects. All opioids, both recreational drugs and medications, when reduced or stopped, can lead to opioid withdrawal symptoms. When withdrawal symptoms are due to recreational opioid use, the term opioid use disorder is used, whereas when due to prescribed medications, the term prescription opioid use disorder is used. Opioid withdrawal can be helped by the use of opioid replacement therapy, and symptoms may be relieved by the use of medications including lofexidine and clonidine.

Opioid agonist therapy (OAT) is a treatment in which prescribed opioid agonists are given to patients who live with Opioid use disorder (OUD). The benefits of this treatment include a more manageable withdrawal experience, cognitive improvement, and lower HIV transmission. The length of OAT varies from one individual to another based on their physiology, environmental surroundings, and quality of life.

<span class="mw-page-title-main">Prescription drug addiction</span> Medical condition

Prescription drug addiction is the chronic, repeated use of a prescription drug in ways other than prescribed for, including using someone else’s prescription. A prescription drug is a pharmaceutical drug that may not be dispensed without a legal medical prescription. Drugs in this category are supervised due to their potential for misuse and substance use disorder. The classes of medications most commonly abused are opioids, central nervous system (CNS) depressants and central nervous stimulants. In particular, prescription opioid is most commonly abused in the form of prescription analgesics.

References

  1. 1 2 3 Wesson DR, Ling W (2003-06-01). "The Clinical Opiate Withdrawal Scale (COWS)". Journal of Psychoactive Drugs. 35 (2): 253–9. doi:10.1080/02791072.2003.10400007. PMID   12924748. S2CID   39160111.
  2. ↑ "Home - Drug Interactions". drug-interactions.medicine.iu.edu. Retrieved 2019-05-08.
  3. ↑ The University of Sydney (2019). "Oxycodone". Australian Medicines Handbook. Retrieved 2019-05-08.
  4. ↑ Smith HS (July 2009). "Opioid metabolism". Mayo Clinic Proceedings. 84 (7): 613–24. doi:10.4065/84.7.613. PMC   2704133 . PMID   19567715.
  5. 1 2 Brennan MJ (March 2013). "The effect of opioid therapy on endocrine function". The American Journal of Medicine. 126 (3 Suppl 1): S12-8. doi:10.1016/j.amjmed.2012.12.001. PMID   23414717.
  6. ↑ Treatment, Center for Substance Abuse (2004). 4 Treatment Protocols. Substance Abuse and Mental Health Services Administration (US).
  7. ↑ Ling W (July 2012). "Buprenorphine implant for opioid addiction". Pain Management. 2 (4): 345–50. doi:10.2217/pmt.12.26. PMC   4283787 . PMID   24654720.
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